RBC Exchange and Depletion Procedures - the UCLA Department ...

Welcome toeSessionsPresented by CaridianBCTPN 306670-723 ©2008 CaridianBCT

Red Blood Cell Exchangeand Depletion ProceduresCOBE Spectra ® Apheresis SystemPN 306670-723 ©2008 CaridianBCT

Red Blood CellExchange (RBCX) ProceduresPN 306670-723 ©2008 CaridianBCT

Presentation Overview• Indications and procedure goals for RBCXprocedures• Overview of operational principles anddata entry• Unique features of RBCX procedures• Helpful hintsPN 306670-723 ©2008 CaridianBCT

Presentation ObjectivesParticipants will be able to• Name two indications for RBCX procedures.• List two procedure goals of RBCX procedures.• Identify four procedure variables that would preventthe expected outcome of the procedure.PN 306670-723 ©2008 CaridianBCT

Indications for RBCX• Sickle cell disease• Thalassemia• Protozoal infections of red blood cells (RBCs)• Incompatible transfusion• Carbon monoxide poisoningPN 306670-723 ©2008 CaridianBCT

Sickle Cell Disease (SCD)• Inherited, chronic disease resulting from theproduction of abnormal hemoglobin S (HbS).- May be homozygous SS (HbSS) or in combination withHbC (HbSC), or with beta thalassemia (HbS Beta).• Most common inherited hematologic disorder.Increased prevalence in African, Mediterranean andIndian populations.PN 306670-723 ©2008 CaridianBCT

Sickle Cell Disease (cont)• Under certain conditions, cells containing HbSbecome sickle shaped and rigid. They increaseblood viscosity and lodge in small vessels,resulting in tissue ischemia and painful crises.• Sickle cells have a shortened survival time,approximately 7 to 20 days, which results inaccelerated hemolysis of RBCs and chronicanemia.PN 306670-723 ©2008 CaridianBCT

Thalassemia• Group of inherited disorders caused bymutations in one or more of the genes thatcode for globin proteins which are part of thehemoglobin molecule.• Result in a deficiency of alpha or beta globinchains, causing reduced production orabsence of HbA.• Prevalent in the Mediterranean basin throughthe Middle East, and India to Southeast Asia.PN 306670-723 ©2008 CaridianBCT

HemoglobinAlpha chainBeta chain= Iron molecule= 2, 3-DPGAlpha chain= Oxygen= Carbon dioxideBeta chainPN 306670-723 ©2008 CaridianBCT

Role of RBCX in Hemoglobinopathies• Replace abnormal patient RBCs with normal donorRBCs to improve oxygen delivery and clinicalcondition more efficiently than simple transfusions.• Maintain the patient’s hematocrit (Hct) at anappropriate level.• Prevent or decrease iron overload associated witheither the disease process or the use of simpletransfusion.PN 306670-723 ©2008 CaridianBCT

Protozoal Infections• Malaria- Mosquito-borne illness caused by infection of RBCswith Plasmodium protozoa.- Symptoms include:• Fever• Chills• Headache• AnemiaPN 306670-723 ©2008 CaridianBCT

Protozoal Infections (cont)• Babesiosis- Tick-borne, malaria-like illness caused byinfection of RBCs with Babesia protozoa.- Symptoms relate to the degree of parasiticload and include:• Fever• Hemolytic anemia• HemoglobinuriaPN 306670-723 ©2008 CaridianBCT

Role of RBCX in Protozoal InfectionsRBCX can be used adjunctively to reduce highparasitic loads observed with protozoal infections,especially with P. falciparum.PN 306670-723 ©2008 CaridianBCT

Other Indications• Incompatible RBC transfusion- Removal of Rh-positive cells fromRh-negative recipient.- Removal of ABO-incompatible RBCs post-transplantor post-transfusion.• Carbon monoxide poisoning- Competition between carbon monoxide (CO) andoxygen for binding sites on hemoglobin.- Removal of CO-saturated RBCs.PN 306670-723 ©2008 CaridianBCT

Spectra System RBCX Procedure Goals• Reduce the number of defective or infectedRBCs and replace them with the appropriateamount of replacement RBCs.• Maintain or alter the patient’s (Hct).• Control fluid balance.PN 306670-723 ©2008 CaridianBCT

Overview ofOperational PrinciplesPN 306670-723 ©2008 CaridianBCT

Fluid PathwayDonorRBCsPatientRBCsACD-APN 306670-723 ©2008 CaridianBCT

RBC Single-Stage Channel SeparationRBC, WBC &Platelet outPlasmareturnedWhole Blood InPN 306670-723 ©2008 CaridianBCT

Data Entry• Sex, height, weight• Patient’s Hct• Average replacement fluid Hct• Desired end Hct for the patient• Fluid balancePN 306670-723 ©2008 CaridianBCT

Data Entry (cont)Patient Hct= 22 %, End Hct= 30 %Average replace Hct= 55 % OK(YES/NO)?The Spectra system uses the Hct values you enterto calculate the pre- and post-procedure red cellvolume of the patient, and the red cell volume ofthe replacement fluid.The system then uses these red cell volumes todetermine the volume of replacement fluidrequired to achieve the desired end results.PN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume CalculationAfter you enter the initial data, the followingscreen appears:Calculate replacement fluid volumeneeded. (YES/NO)?To let the Spectra system calculate the requiredreplacement volume, press YES.PN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume Calculation (cont)Enter the desired fraction of red cells remaining (FCR).The default FCR is 40%.Enter desired Fraction of red cellsremaining: FCR = {40}% (YES/NO)?PN 306670-723 ©2008 CaridianBCT

What is FCR?FCR is the percentage of the patient’s original RBCsremaining in the patient at the end of the procedure.100%patient HbS RBCRBCX80%donor HbA RBC20% patient HbS RBC = FCR%PN 306670-723 ©2008 CaridianBCT

Using the FCRDonorRBC/HbA(50%)HbAPatientRBC/HbS(50%)RBCX20% HbSFCR40%PN 306670-723 ©2008 CaridianBCT

Using the FCR to Meet HbS GoalsDesired end HbS conc----------------------------- x 100 = FCRStarting HbS concExample:Desired end HbS = 20%Starting HbS = 50%20--- x 100 = 40%50 During data entry, enter 40% as the desired FCR.PN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume CalculationEnter the desired FCR:Enter desired Fraction of red cellsremaining: FCR = {20}%The Spectra system calculates and displaysthe run results:Replace= 3398ml, FB= 100%, FCR= 20%,End Hct= 30%, time= 151 min (YES/N0)?PN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume Calculation (cont)Changing the FCR changes the replacement fluidvolume required.Example:Enter desired Fraction of red cellsremaining: FCR = {40}%Replace= 1934 ml, FB=100%, FCR= 40%,End Hct= 30%, time= 87 min OK(YES/N0)?PN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume Calculation (cont)Two options are available for calculating requiredreplacement fluid volume prior to the procedure:•Spectra system calculation.•“Replacement Volume Estimation Tool for RBC ExchangeProcedures” (available at www.caridianbct.com).PN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume Estimation ToolPN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume• Replacement fluid volume can bedetermined by- Value from the calculation tool or fromthe Spectra system- Physician’s order- Volume the blood bank has availablePN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume EntryOnce you enter the initial data, the following screenappears:Calculate replacement fluid volumeneeded (YES/NO)?To enter a specific replacement fluid volume, pressNO. The Spectra system then prompts you to enterthe replacement fluid volume:Enter total replacement fluid volume:{ 0} ml.PN 306670-723 ©2008 CaridianBCT

Replacement Fluid Volume Entry (cont)Enter the available replacement fluid volume:Enter total replacement fluid volume:{1500}ml.The Spectra system calculates and displays therun results:Replace=1500 ml, FB=100%, FCR= 48%,End Hct= 30%, time= 68 min OK(YES/N0)?PN 306670-723 ©2008 CaridianBCT

Data Influencing Predicted Run ResultsPredictedrunresultsPN 306670-723 ©2008 CaridianBCT

Unique Features ofRBCX ProceduresPN 306670-723 ©2008 CaridianBCT

AC Infusion RateO.9 mL/min/L TBV• AC data screen is unavailable during the procedure.• The default AC infusion rate is 0.9 mL/min/L TBV.• AC infusion rate alarm limit is 1.4 mL/min/L TBV.• The citrate in the replacement fluid is not considered.PN 306670-723 ©2008 CaridianBCT

AC Volume Calculation ToolINPUT DATAAC VOL TO PATIENTTBV (ml) AC Volume (ml) NAReplace Volume (ml)Starting Hct (%)AC VOL TO WASTE BAGEnd Hct (%) AC Volume (ml) NAReplace Hct (%)FCR (%)Fluid Balance (%)AC RatioClick Here ForInstructions ForUseAC VOL TO PATIENTINPUT DATATBV (ml) 5000 AC Volume (ml) 213Replace Volume (ml) 2210Starting Hct (%) 28AC VOL TO WASTE BAGEnd Hct (%) 30 AC Volume (ml) 140Replace Hct (%) 60FCR (%) 40Click Here ToFluid Balance (%) 100Return To ACAC Ratio 13CalculationsClick Here ToReview ExampleThis calculation tool helps to estimate the ACvolume delivered from the AC bag to the patientand to the waste bag during an RBCX ordepletion procedure.PN 306670-723 ©2008 CaridianBCT

RinsebackRinseback is notrecommended, becausethe prediction for endHct and FCR does notconsider the rinsebackvolume.Rinseback(345)End (+345)End (+245)Start: (0)Run (blood prime)Divert(100)Run(-100)Rinseback(345)PN 306670-723 ©2008 CaridianBCT

Helpful Hints• Enter accurate patient Hct. This is a MUST!• Know the Hct and volume of each unit ofreplacement RBCs.• If the RBC units contain Adsol solution, a spunHct will be inaccurate.• For sickle cell patients, screen the replacementRBC units for sickle cell trait.• Be aware that platelet and WBC counts candecrease 30% to 50%.PN 306670-723 ©2008 CaridianBCT

Helpful Hints (cont)• Consider leukoreducing replacement RBC unitsprior to the procedure.• Entering a combination of values that approachupper and/or lower extremes will result in invalidprocess time or replacement fluid volumealarms.• Target time can be changed only by changingthe collect/replace volume.• After the “divert prime operation,” changes toreplacement fluid Hct are invalid.PN 306670-723 ©2008 CaridianBCT

Red Blood Cell (RBC)Depletion ProceduresPN 306670-723 ©2008 CaridianBCT

Presentation Overview• Indications for RBC depletion procedures• Procedure goals for RBC depletion procedures• Data entryPN 306670-723 ©2008 CaridianBCT

Presentation ObjectivesParticipants will be able to• List one indication for an RBC depletion procedure.• Identify one RBC depletion procedure goal.• Name the data entry value that causes the Spectrasystem to perform an RBC depletion procedure.PN 306670-723 ©2008 CaridianBCT

Indications for RBC Depletion• Polycythemia vera• Iron overload- Primary hemochromatosis- Secondary hemochromatosis• Iron-loading anemia• Chronic transfusionPN 306670-723 ©2008 CaridianBCT

Polycythemia Vera• Myeloproliferative disorder characterized byuncontrolled production of normal RBCs,granulocytes, and platelets, resulting in Hcts ashigh as 80%.• Major symptoms result from an increase in RBCmass and blood viscosity. Symptoms include:- Increased blood pressure- Headache- Visual disturbancesPN 306670-723 ©2008 CaridianBCT

Hemochromatosis• Primary hemochromatosis is a genetic disorderthat interferes with iron metabolism. It results inexcess iron being deposited in organs and tissue.• Secondary hemochromatosis can result fromiron-loading anemias such as thalassemia, orfrom chronic transfusion.PN 306670-723 ©2008 CaridianBCT

Procedure Goals• Rapid removal of greatly elevated numbers ofRBCs to reduce blood viscosity and red cellvolume, or removal of RBCs to reduce iron loadand maintain normal iron levels.• Control of the fluid balance by replacementof removed volume with appropriate fluids.PN 306670-723 ©2008 CaridianBCT

RBC Depletion vs. PhlebotomyAutomated RBC depletion can remove largervolumes of RBCs than manual phlebotomy can, andallows volume replacement with appropriate fluids.PN 306670-723 ©2008 CaridianBCT

Data Entry• Sex, height, weight• Patient’s Hct• Average replacement fluid Hct Enter 0%• Desired end Hct for the patient• Fluid balancePN 306670-723 ©2008 CaridianBCT

Data Entry (cont)1. Verify the entered Hcts:Patient Hct= 65 %, End Hct= 45 %Average replace Hct= 0 %. OK(YES/N0)?2. Once you enter the initial data, the following screen appears:Calculate replacement fluidneeded (YES/NO)?3. To let the Spectra system calculate and display the runresults, press YES:Replace=1360 ml, FB=100%, FCR= 100%,End Hct= 45%, time= 36 min OK(YES/N0)?PN 306670-723 ©2008 CaridianBCT

References1. Altman, A.J., “Polycythemia Vera,” eMedicine,October 31, 2002,(September 20, 2005).2. Cunha, B.A., “Babesiosis,” eMedicine, August 26,2002, (September 20, 2005).3. Hassett, A.C. and Kiss, J.E., “HereditaryHemochromatosis,” Transfusion Medicine Update,The Institute for Transfusion Medicine, August1997.PN 306670-723 ©2008 CaridianBCT

References (cont)4. McCleod, B.C. “Introduction to the Third SpecialIssue: Clinical Applications of TherapeuticApheresis,” Special Issue: Clinical Applications ofTherapeutic Apheresis, Journal of ClinicalApheresis, Vol. 15, No. 1/2, 2000.5. Mehta, P.N., “Malaria.” eMedicine, June 23, 2004,(September 20, 2005).6. “Special Issue: Clinical Applications ofTherapeutic Hemapheresis,” Journal of ClinicalApheresis, Vol. 8, No. 4, 1993.PN 306670-723 ©2008 CaridianBCT

References (cont)7. Takeshita, K., “Thalassemia, Beta,” eMedicine,February 20, 2002,(September 20, 2005).8. “Thalassemia,” Dr. Joseph F. Smith MedicalLibrary, Copyright 1999-2001.(September 20, 2005).PN 306670-723 ©2008 CaridianBCT